Patient Information

RESPONSIBLE PARTY INFORMATION

IF PATIENT IS UNDER AGE 18, PLEASE COMPLETE THIS SECTION

DENTAL INSURANCE INFORMATION

EMERGENCY INFORMATION

MEDICAL HISTORY

Please fill out this section to the best of your knowledge. It is important for us to be aware of any health issues that may affect the treatment you receive from our office. This information is kept strictly confidential.

Please check any of the following that you have had or currently have:

DENTAL HISTORY

Please check any of the following which apply to you, and add any relevant comments.
By clicking the "Submit Form" button below, you confirm that you have read and consent the BENEFITS OF ORTHODONTICS: AESTHETICS, HEALTH AND FUNCTION. TEETH, GUMS AND JAWS ARE AN INTRICATE BODY PART AND CAN FAIL TO RESPOND TO TREATMENT. IF GOOD ORAL HYGIENE IS NOT PRACTICED, TOOTH DECAY AND ENLARGED GUMS CAN RESULT. JOINT DISCOMFORT AND ROOT SHORTENING ARE OBSERVED IN A SMALL PERCENTAGE OF CASES. TEETH CHANGE THOUGHOUT OUR LIFETIME AND THERE CAN BE SOME MOVEMENT OF TEEH AND SOME CHANGE AFTER TREATMENT. I HAVE READ AND UNDERSTAND THIS PARAGRAPH; I AGREE TO INFORM THIS OFFICE OF ANY CHANGES IN MY MEDICAL OR DENTAL HISTORY. I ALSO AUTHORIZE THE DOCTOR TO PERFORM A COMPLETE ORTHODONTIC EVALUATION.
By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.